UCC FINANCING STATEMENT
FOLLOW INSTRUCTIONS (front and back) CAREFULLY
SAMPLE FORM
A. NAME & PHONE OF CONTACT AT FILER (optional)
___________________________________________________________
B. SEND ACKNOWLEDGEMENT TO: (Name and Address)
1. DEBTOR'S EXACT FULL LEGAL NAME - insert only one debtor name (1a or 1b) - do not abbreviate or combine names
1a.. ORGANIZATION'S NAME
OR
1b. INDIVIDUAL'S LAST NAMEFIRST NAMEMIDDLE NAMESUFFIX
1c. MAILING ADDRESSCITYSTATEPOSTAL CODECOUNTRY
1d. TAX ID# SSN OR EINADD'L INFO RE ORGANIZATION DEBTOR
1e. TYPE OF ORGANIZATION
1f. JURISDICTION OF ORGANIZATION
1g. ORGANIZATIONAL ID#, if any
NONE
2. ADDITIONAL DEBTOR'S EXACT FULL LEGAL NAME - insert only one name (2a or 2b) - do not abbreviate or combine names
2a. ORGANIZATION'S NAME
OR
2b. INDIVIDUAL'S LAST NAMEFIRST NAMEMIDDLE NAMESUFFIX
2c. MAILING ADDRESSCITYSTATEPOSTAL CODECOUNTRY
2d. TAX ID# SSN OR EINADD'L INFO RE ORGANIZATION DEBTOR
2e. TYPE OF ORGANIZATION
2f. JURISDICTION OF ORGANIZATION
2g. ORGANIZATIONAL ID#, if any
NONE
3. SECURED PARTY'S NAME (or NAME of TOTAL ASSIGNEE of ASSIGNOR S/P) - insert only one secured party name (3a or 3b)
3a. ORGANIZATION'S NAME
OR
3b. INDIVIDUAL'S LAST NAMEFIRST NAMEMIDDLE NAMESUFFIX
3c. MAILING ADDRESSCITYSTATEPOSTAL CODECOUNTRY
4. This FINANCING STATEMENT covers the following collateral:
5. ALTERNATIVE DESIGNATION (if applicable):
6. This FINANCING STATEMENT is to be filed (for record) in the REAL ESTATE RECORDS Attach Addendum (if applicable)
7. Check to REQUEST SEARCH REPORT(S) on Debtor(s) [ADDITIONAL FEE] [optional]
FILING OFFICE COPY - NATIONAL UCC FINANCING STATEMENT (FORM UCC1) (REV. 07/29/98)
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